Can Vaccines Break Cholera's Deadly Hold On Haiti?

Haitians suffering from cholera symptoms rest at the treatment center in Mirebalais, a dusty town north of Port-au-Prince, Haiti, last June. The cholera epidemic in Haiti began in Mirebalais, believed to be the result of overflowing bathrooms from a nearby U.N. compound.

Antonina Tanis, 56, contracted cholera in November 2011. "I was vomiting. I had diarrhea," she recalls. "I couldn't stand up. I fell like three or four times trying to get to my feet." She says there's no way she could have gotten herself to medical care, and she would have died if her neighbors hadn't carried her to a clinic.

Larison Fiquaire lost his 26-year-old son, Etienne, to cholera in the fall. Fiquaire, 65, says when he brought his son to the hospital, the doctor told him, "I'm sorry, you came too late. If you'd come sooner, maybe we would have saved him." Etienne died later that night.

Edison Charles, 19, contracted cholera early in 2011 and spent six days in a clinic. He says the disease is all over the Port-au-Prince slum of Cite Soleil: "The cholera is like death; it's going from door to door."

A garbage and sewage filled channel cuts through Cite Soleil, a slum in Port-au-Prince, Haiti. Poor sanitation and lack of access to clean drinking water are the main factors that contribute to the spread of cholera.

Jason BeaubienNPR

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Originally published on May 23, 2012 10:05 am

The cholera outbreak in Haiti is currently the worst ongoing episode in the world.

Over the past 15 months, it has sickened more than half a million people and killed roughly 7,000. The bacteria has now spread throughout the Caribbean island, and medical experts say it will be around for years to come.

Partners in Health, a Boston-based nonprofit, is planning to launch an unprecedented cholera vaccination campaign to try to curb the outbreak — but it faces many challenges, including a shortage of the vaccine.

For decades, Haiti had been considered a potential cholera flash point. Even before the 2010 earthquake, roughly 50 percent of Haitians lacked access to clean water, and 80 percent didn't have adequate sewage systems, according to the World Health Organization.

Danger In The Slums

Antonina Tanis lives in the Port-au-Prince slum of Cite Soleil. The 56-year-old says there are no toilets in her neighborhood.

"We don't have no toilet at all. We do it in the sea," she says.

By "the sea," Tanis is referring to brackish tidal canals that flush in and out of the slum. Residents perch on a cement ledge over one of the canals when they have to relieve themselves. Cite Soleil is also known for "flying toilets," a practice of going to the bathroom in a plastic bag and then letting it "fly" out the window.

Ever since cholera appeared in Haiti in October 2010, it's been rampant in Cite Soleil. Tanis came down with it in November 2011. She says the vomiting hit her so hard, she couldn't even stand up.

"I was totally out of it," Tanis recalls. "I couldn't stand. I'd stand and I'd fall back down. I was dehydrated and about to die."

Her neighbors carried her to a nearby cholera treatment clinic, and within a week, she completely recovered.

Thousands of others in Haiti haven't been so fortunate. Several of Tanis' neighbors recount how their kids, wives or parents died from the disease.

Outbreak's Origins

Jon Lascher, Haiti program manager for Partners in Health, says the cholera outbreak began miles away, on Haiti's Central Plateau.

"This is where cholera started. The first cases tested positive for cholera from people in Mirebalais," Lascher says.

The group's cholera treatment center in Mirebalais is little more than a glorified tent filled with rows of tarp-covered beds.

"When there was a peak of cholera, we were seeing up to 100 patients a day at this facility," he says.

The number of patients has fallen dramatically recently, but is expected to spike again when the rainy season returns.

The cholera outbreak began near a United Nations peacekeeping base housing Nepalese soldiers. The strain of cholera that raced across Haiti is nearly identical to the predominant strain in Southeast Asia.

It's widely believed in Haiti that overflowing outhouses at the U.N. compound were the source of the deadly outbreak. An independent study published in the Emerging Infectious Diseases journal drew a similar conclusion.

Questions Surround Vaccine Program

In the coming weeks, Partners in Health plans to launch an unprecedented — and somewhat controversial — vaccination campaign against the disease.

Lascher says ultimately the way to eliminate cholera from Haiti is through building water and sewage treatment systems, but he says that could take years.

"While we're waiting, we know that there's a safe and effective oral cholera vaccine that can help prevent people from getting cholera again. Why wouldn't we do that? I think it would be certainly expected anywhere else in the world," he says.

But the vaccination proposal has been criticized by some Haitians and questioned by other aid agencies.

Partners in Health is planning to use a relatively new vaccine, Shanchol. And because of limited global supply of the drug, as well as logistical concerns, Partners in Health is only planning to offer it to 100,000 people — or just 1 percent of the Haitian population.

The Platform of Haitian Human Rights Organizations issued a statement in December saying the money for a vaccine campaign should be invested instead in upgrading water and sewage systems.

Wendy Lai, the medical director in Haiti for the Swiss arm of Doctors Without Borders, says her group has decided not to participate in the vaccine campaign.

"My concern is that when people talk about vaccines, they sort of think it's going to be the magic bullet and wipe out cholera forever," Lai says. "Some vaccines are like that almost — smallpox was. But the cholera vaccine is not like that."

According to the World Health Organization, Shanchol's efficacy rate ranges from 45 percent to 86 percent. And people immunized with Shanchol would need to be revaccinated every two or three years.

Lai questions how effective this limited campaign will be, and says she is concerned it could be a distraction.

"You know, the best vaccine for cholera is water and [a] sanitation system," she says.

Another issue is that Haiti has a very poor record when it comes to immunization campaigns.

Coverage rates in Haiti for established, routine vaccines such as measles, rubella and polio are extremely low.

Clean Water, Sanitation Still Top Priorities

The country director for the Centers for Disease Control and Prevention, John Vertefeuille, says public health experts are very interested in seeing how this vaccine campaign goes.

"Cholera vaccine has never been used in an acute, ongoing epidemic of cholera, and so there are some unanswered questions about how effective the vaccine will be in this population," he says.

He says the CDC supports the vaccination drive, but he adds that improving Haitians' access to treated water and sanitation remain priorities in the current outbreak.

Partners in Health officials say the bottom line for them is that the cholera vaccine is one more tool that could save lives. And they plan to start the first round of vaccinations in March.

Copyright 2013 NPR. To see more, visit http://www.npr.org/.

Transcript

ROBERT SIEGEL, HOST:

Haiti is now in the throes of the worst ongoing cholera outbreak in the world. In 15 months, it has sickened more than half a million people and killed roughly 7,000. The disease has spread through the Caribbean nation and medical experts say it will be around for years to come.

The non-profit Partners in Health is planning to launch an unprecedented cholera vaccination campaign to curb the outbreak.

But NPR's Jason Beaubien reports that it faces many challenges, including a vaccine shortage.

JASON BEAUBIEN, BYLINE: For decades, Haiti had been considered a potential cholera flashpoint, a place just waiting for cholera bacteria to come and flourish. Even before the 2010 earthquake, roughly 50 percent of Haitians lacked access to clean water and 80 percent didn't have adequate sewage systems, according to the World Health Organization.

ANTONINA TANIS: (Foreign language spoken)

BEAUBIEN: In the Port-au-Prince slum of Cite Soleil, 56-year-old Antonina Tanis says there are no toilets in her neighborhood.

TANIS: (Through Translator) We don't have no toilet at all. We do it in the sea.

BEAUBIEN: By the sea, Tanis is referring to brackish tidal canals that flush in and out of the Cite Soleil. Residents perch on a cement ledge over one of the canals when they have to relieve themselves. The slum is also known for flying toilets, a practice of going to the bathroom in a plastic bag and then letting it fly out the window.

Ever since cholera appeared in Haiti in October of 2010, it's been rampant in Cite Soleil. Tanis came down with it in November. She says the vomiting hit her so hard she couldn't even stand up.

TANIS: (Through Translator) I was totally out of it. I couldn't stand. I'd stand and I'd fall back down. And I was dehydrated and about to die.

BEAUBIEN: Her neighbors carried her to a nearby cholera treatment clinic and within a week she'd completely recovered. Thousands of others in Haiti, however, haven't been so fortunate. Several of Tanis' neighbors recount how their kids, wives, parents died from the disease.

The outbreak began miles away on Haiti's Central Plateau.

(SOUNDBITE OF ROOSTER)

JON LASCHER: This was where cholera started. The first cases tested positive for cholera from people in Mirebalais.

BEAUBIEN: Jon Lascher is the Haiti program manager for Partners in Health. He's standing in the group's cholera treatment center in Mirebalais. The clinic is little more than a glorified tent filled with rows of tarp-covered beds.

LASCHER: When there was a peak of cholera, we were seeing up to 100 patients a day at this facility.

BEAUBIEN: The number of patients has fallen dramatically recently but is expected to spike again when the rainy season returns.

The cholera outbreak began near a United Nations peacekeeping base housing Nepalese soldiers. The strain of cholera that raced across Haiti is nearly identical to the predominant strain in Southeast Asia.

It's widely believed in Haiti that overflowing outhouses at the U.N. compound were the source of the deadly outbreak and an investigation led by French researchers drew a similar conclusion.

In the coming weeks, Partners in Health plans to launch an unprecedented and somewhat controversial vaccination campaign against the disease. Jon Lascher says, ultimately, the way to eliminate cholera from Haiti is through building water and sewage treatment systems, but he says that could take years.

LASCHER: While we're waiting, we know that there's a safe and effective oral cholera vaccine that can help prevent people from getting cholera again. Why wouldn't we do that? I think it would be certainly expected anywhere else in the world.

BEAUBIEN: But the vaccination proposal has been criticized by some nations and questioned by some other aid agencies. Partners in Health is planning to use a relatively new vaccine, Shanchol. Because of limited global supply of the drug, as well as logistical concerns, Partners in Health is only planning to offer it to 100,000 people, or just one percent of the Haitian population.

The platform of Haitian Human Rights Organizations issued a statement last month, saying the money for a vaccine campaign should be invested instead in upgrading water and sewage systems.

Wendy Lai, the medical director in Haiti for the Swiss arm of Doctors Without Borders, says her group has decided not to participate in the vaccine campaign.

WENDY LAI: I guess my concern is that when people talk about a vaccine, they sort of think it's going to be the magic bullet and, you know, wipe out cholera forever and it's not. Some vaccines are like that, almost. You know, small pox was, but the cholera vaccine is not like that.

BEAUBIEN: According to the World Health Organization, Shanchol's efficacy rate ranges from 45 to 86 percent and people immunized with Shanchol would need to be revaccinated every two or three years.

Lai questions how effective this limited campaign will be and she says she's concerned it could be a distraction.

LAI: You know, the best vaccine for cholera is a water and sanitation system.

BEAUBIEN: Another issue is that Haiti has a very poor record when it comes to immunization campaigns. Coverage rates in Haiti for established routine vaccines, such as measles, rubella and polio, are extremely low.

The country director for the Centers for Disease Control and Prevention, John Vertefeuille, says public health experts are very interested in seeing how this vaccine campaign goes.

JOHN VERTEFEUILLE: Cholera vaccine has never been used in an acute, ongoing epidemic of cholera. And so there are some unanswered questions about how effective the vaccine will be in this population.

BEAUBIEN: He says the CDC supports the vaccination drive, but he adds that improving Haitians' access to treated water and sanitation remain the top priorities right now in this outbreak.

Partners in Health officials say the bottom line for them is that the cholera vaccine is one more tool that could save lives and they plan to start the first round of vaccinations in February or March.